Daily Self-Check July 7, 2021 Please complete this each day prior to proceeding to the theatre. Date Name First Last Do you have any of the following new or worsening symptoms?(Required)Symptoms should not be chronic or related to other known causes or conditions, including recent vaccination. Fever and/or chills Difficulty breathing or shortness of breath Cough Sore throat, trouble swallowing Runny nose/stuffy nose or nasal congestion Decrease or loss of smell or taste Nausea, vomiting, diarhea, abdominal pain Not feeling well, extreme tiredness, sore muscles Pink Eye (Conjunctivitis) Headache (unusual, long-lasting) Do you have any of the above symptoms that are NEW or WORSENING? Yes No In the last 14 days, have you travelled outside of Canada AND been advised to quarantine per the federal quarantine requirements?(Required) Yes No Have you had close contact with a confirmed or probable case of COVID-19?(Required) Yes No Has a doctor, health care provider, or public health unit told you that you should currently be isolating (staying at home)?(Required) Yes No PhoneThis field is for validation purposes and should be left unchanged.